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Department: Enhanced Care Management (ECM) Reports To: Registered Nurse Clinical Case Consultant Classification: Non-Exempt Work Arrangement: Hybrid – Hiring County Compensation: $30.00 - $35.00 per hour Schedule: Monday – Friday | 8:30 AM – 5:00 PM Open Positions: 2 About Pacific Health Group At Pacific Health Group, we are transforming healthcare by addressing social determinants of health and delivering innovative, community-based solutions that improve lives. Through programs such as Enhanced Care Management (ECM), Community Supports, Behavioral Health Services, Community Health Workers, Street Medicine, and other whole-person care initiatives, we help individuals navigate complex healthcare systems and access the resources they need to thrive. We meet individuals where they are—with compassion, dignity, respect, and a commitment to whole-person care. Our work focuses on improving outcomes for individuals experiencing homelessness, serious mental illness, substance use disorders, chronic health conditions, justice involvement, and other complex social and medical challenges. If you are passionate about improving healthcare outcomes and supporting vulnerable populations through innovative community-based care, we invite you to join our team. Position Summary The Licensed Vocational Nurse (LVN) serves as a vital member of the Enhanced Care Management (ECM) team, supporting high-risk Medi-Cal members with complex medical, behavioral health, and social needs throughout Hiring County. Working under the supervision of the Registered Nurse Clinical Case Consultant, the LVN assists with care coordination, member assessments, health education, medication reconciliation, transitions of care, chronic disease management, outreach, and clinical documentation. The LVN collaborates closely with Lead Care Managers, Community Health Workers, Behavioral Health staff, healthcare providers, hospitals, health plans, and community-based organizations to improve health outcomes and reduce barriers to care. This role requires a combination of remote work, field-based member visits, community outreach, provider collaboration, and care coordination activities throughout Hiring County. Essential Duties and Responsibilities Clinical Care Coordination Support care coordination activities for members enrolled in the CalAIM Enhanced Care Management (ECM) program. Assist members in understanding treatment plans, discharge instructions, medications, and provider recommendations. Conduct clinical outreach to members, caregivers, providers, hospitals, and health plans. Monitor member progress and communicate clinical concerns to the Registered Nurse Clinical Case Consultant. Assist in identifying barriers to care and developing solutions that support member success. Support continuity of care and transitions following hospitalizations, emergency department visits, and other healthcare events. Assist with coordination of specialty care, behavioral health services, and community-based resources. Member Assessments & Clinical Support Conduct health screenings and assessments within LVN scope of practice. Collect and document health information, vital signs, medication information, and clinical observations. Assist with chronic disease management support for conditions such as diabetes, hypertension, COPD, heart disease, and other chronic illnesses. Monitor member symptoms and escalate concerns appropriately. Provide health education regarding disease management, medication adherence, preventive care, and wellness strategies. Medication Management Support Perform medication reconciliation activities under RN supervision. Educate members regarding prescribed medications and treatment plans. Monitor medication adherence and identify barriers to compliance. Communicate medication concerns to the RN, providers, and care team members. Assist in coordinating medication-related resources and services. Community Outreach